What to ask your doctor before choosing surgery

By Christie Aschwanden, Special to The Washington Post

Wednesday, December 4, 2013

More than 15 million Americans undergo surgery each year, but there’s growing recognition that some elective operations may be more about the surgeon’s preference than about the patient’s need for the procedure. Researchers at the Dartmouth Institute for Health Policy & Clinical Practice released a report last year showing that some doctors routinely send their patients to surgery more often than other physicians do. For instance, Medicare patients in Casper, Wyo., were found to be more than seven times as likely to get elective back surgery for back pain as Medicare patients in Honolulu.

When surgeons develop expertise at a particular procedure, they can begin to see every patient as a potential candidate, says Rosemary Gibson, an editor for the journal JAMA Internal Medicine and the author of “The Treatment Trap.” One physician she interviewed for the book described how a hospital that specializes in heart bypass surgery performed operations on people whose condition did not require them. “They had a production line and were just racking them up,” he told her.

So how do you make sure that when your doctor suggests surgery, it’s the best decision for you?

Begin by asking a lot of questions. “Is this surgery necessary?” is the most important, of course, says David Meyers, director of the Center for Primary Care, Prevention, and Clinical Partnerships at the Agency for Healthcare Research and Quality. The center publishes a list of 12 questions to ask before opting for surgery. Among them: What are the alternatives? What are the risks? What will happen if I don’t have this operation?

Never choose surgery without exploring nonsurgical options first, advises Joshua Jacobs, president of the American Academy of Orthopaedic Surgeons and chairman of orthopedic surgery at Rush University Medical Center in Chicago. In general, surgery is recommended only when less invasive treatments have failed or when it’s clear that a surgical repair will deliver a better result than nonsurgical treatments, Jacobs says.

A new surgical risk calculator developed by the American College of Surgeons can help, says Clifford Ko, director of the group’s division of research and optimal patient care. The calculator allows your doctor to enter information about you and the surgical procedure you’re considering to estimate your risk of complications using a database of records from patients at more than 500 hospitals.

Some orthopedic procedures, such as joint replacements, involve devices made by multiple companies. In cases where more than one product can do the job, “ask your surgeon: Why this device?” Jacobs says. “What’s been your experience with this particular one?” Ask if there are any studies or statistics on this particular product that show how it compares to others.

Proceed with extra caution if your doctor is recommending a brand-new procedure or device. Whenever a new surgical technique comes out, “everyone’s excited about the newest thing and they jump on the bandwagon, but you really need to wait and see what the outcomes will be,” says Frederick L. Greene, a clinical professor of surgery at the University of North Carolina School of Medicine and a member the American College of Surgeons’ patient education committee. Sometimes the newfangled thing turns out to be no better or even worse than the older, more established one. Many hospitals are now touting robotic surgery for elective procedures, but such shiny new technologies aren’t always your best choice, Greene says.

“As Americans, we have a real love of new technologies and the wow factor,” Meyers says. “But just because it’s new or it uses computers or robots doesn’t mean it’s better.” If your surgeon is pushing a new technology, it’s worth getting a second opinion from someone who doesn’t use it, Meyers says.

Beware of hospitals and doctors with a financial interest in an expensive procedure, Gibson says. A 2012 study found that information about robotic gynecologic surgery on hospital Web sites provided an incomplete picture of the benefits and risks of such procedures, and in August, researchers at Johns Hopkins University published a study suggesting that complications from robotic laparoscopic surgery may be underreported. Gibson says that when doctors or hospitals purchase expensive equipment such as robotic surgical tools, they have an incentive to overuse it so they can recoup their costs.

Surgery is a big deal, so ask for a second opinion before making a decision. “If I asked a doctor for a second opinion and they balked, I would be worried,” Meyers says. “It’s reasonable to inquire about how often they do the procedure or operate on people similar to you,” Jacobs says. “If the surgeon does 100 or 200 procedures per year, you’ll probably have a better outcome than if they only do 10.”

Before you schedule surgery, ask your surgeon how long it will take to recover and what limitations you’ll face during the post-op period, Jacobs says. Also find out what you can do to maximize your recovery. Some operations require physical therapy or other rehabilitation to achieve best results.

Only agree to surgery once you understand what results you can expect and how these compare to your other options.